Wrapping Care Around Those Who Need it Most

On December 6, the Minister of Health and Long-Term Care announced that Ontario is creating 19 “Health Links” to improve care for high-needs patients, such as seniors and people with complex conditions.  While initially the focus will be on providing more integrated care to the five per cent of Ontarians who rely on two-thirds of the health care budget, there’s little doubt that the lessons learned will ultimately strengthen our system for all.   

So what does “more integrated” mean?

In its simplest form, greater integration means that patients are supported by an intradisciplinary care team collaborating and communicating to “wrap care” around them. 

Consider Mrs. Smith, an 86-year old widow living with multiple chronic conditions.  She has been without a primary care provider since her family doctor moved out of town a year ago, and during that time her health has dramatically declined.  Over the past 12 months, she has been to the emergency department twice, as well as two different walk-in clinics, one urgent care centre, and no fewer than six different pharmacies to fill her medications.  Each time she speaks to a new health care provider, she has to repeat her complex medical history, a task made more difficult by her worsening dementia.   Although she is struggling to manage at home, Mrs. Smith currently does not receive any in-home care, nor is she aware that an opportunity for her to do so exists.  Without any close friends or family nearby and no reliable form of transportation, she struggles with a lack of social interaction and lacks the ability to prepare adequate, nutritious meals.  Sadly, she is not only experiencing a poor quality of life, but her trajectory suggests that without a significant intervention, she is headed for further decline that will require intensive – and costly – care.

Clearly, Mrs. Smith would benefit from an integrated care team that understands her needs and works together to support her throughout the care continuum.   In its ideal state, such care might look like this:

Rather than expecting Mrs. Smith to fit into the health care system, a team of care providers collaborate to make the system work for her.  Through Health Care Connect, a provincial program administered by CCACs, Mrs. Smith is connected with Dr. Johnson, a primary care provider in her community who is accepting new patients.  Dr. Johnson immediately identifies the need for specialized care and refers Mrs. Smith to two specialists who can help manage her chronic conditions.   He also refers Mrs. Smith to the CCAC and Betty, a CCAC care coordinator, visits her at home.  Recognizing that Mrs. Smith requires regular nursing care to address her diabetic foot ulcers, physiotherapy to improve her mobility, and assistance with bathing, Betty arranges for Mrs. Smith to receive this care at home.  Betty’s in-home assessment also provides valuable information about Mrs. Smith’s living conditions, and she connects Betty with an adult day program for people living with dementia, as well as the local Meals on Wheels program.

Importantly, Dr. Johnson, the two specialists, CCAC Care Coordinator Betty and the in-home service providers conference regularly about Mrs. Smith’s care and adjust their collaborative efforts as necessary.  Together, they work towards meeting Mrs. Smith’s care goals as articulated by her and established in a single, integrated care plan.  And should Mrs. Smith end up in the emergency department, her team will work with hospital staff to ensure she has the appropriate care in place to facilitate a safe discharge and avoid future readmission to hospital.

This collaboration isn’t a “nice to have” – it’s essential to providing holistic care, reducing duplication, and ensuring that our precious health care resources are used wisely.  While many aspects of the above scenario are already underway (here in Central West we regularly collaborate with our primary care, hospital, and service provider partners, for example), there is still much to be done.  It’s about more than simply “breaking down silos” (a popular analogy in health care, and for good reason); it’s about acknowledging that each “silo” plays a fundamental role in supporting a person’s health, and that person-centred care requires us to seek opportunities for enhanced collaboration.  Health Links compel us to do just that – and as our population ages (to the tune of twice as many Ontarians aged 65+ over the next two decades, according to the recently-released Seniors Strategy), our professional obligation to do better also becomes a practical one as we grapple with unprecedented demands on our health care system.

I am tremendously excited about the potential of this focussed collaboration and eager to contribute the knowledge and skills of our health care professionals.  We are fortunate in Central West to have many strong relationships with our system partners, and this solid foundation is already serving us well as we work together to develop our local Health Links in both North Etobicoke-Malton and Dufferin.  As we do so, we will continue to keep Mrs. Smith – and the estimated 685,000 high-needs Ontarians like her – front, centre, and top of mind.

Cathy

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